3. Complications y polyhydramnios wv anemia A abruptio placenta YX prematurity fi postpartum hemorrhage toxemia an antigen-antibody reaction Which. MPABILITY — G. BLOOD INCOM ction of fetal red blood cells Causes excessive destruction * Mother is Rh ne; tive and the fetus is Rh positive (beca her ig either a homozygous or a heterozygous pp the father is eit positive) © Mother is Type O and the fetus is either Type A or Type p (because the father is either Type A or Type B) ; H. DYSTOCIA - broad term for abnormal or difficult labor and delivery 1. Uterine inertia - sluggishness of contractions a. Causes * Inappropriate use of analgesic3 * Pelvic bone contraction * Poor fetal position * Overdistention — due to multiparity, multiple Pregnancy, polyhydramnigs or excessively large baby : ‘Types * Primary (hypertonic) uterine dysfunction — relaxations are inadequate and mild, thus are ineffective. Since uterine muscles are in a state of greater-than-normal tension, thé latent phas® of the first stage of labor is prolonged. Treatment: Sedate patient. * Secondary (hypotonic) uterine dysfunction - contractions have been good but gradually become infrequent and of poor quality and cervical dilatation stops. Treatment: Stimulate labor by either oxytocin administration or amniotomy. 2. itate delivery ~ labor and delivery that is completed in less than 3 hours after the onset of true labor pains, Probably due to multiparity or following oxytocin administration or amniotomy. Can lead.to: * extensive lacerations * abruptio placenta * hemorrhage due to sudden release of pressure, leading to shock 3. Prolonged labor ~ in primis, labor lasting more than 18, hours and in multi S, more than 12 hours. Can lead to:d. Anesthettc of choice Is Caudal anesthesia fi oe pushless and painless delivery. foCetones Gravidocardlacs are@iot allow 49 push with contractions (to prevent SaWa maneuver Which increases venous return to an already weak, damaged heart). Low forceps, therefore, is the best method of delivery. a e. Ergotrate and other Oxytocics, scopolamine, die tilbestrol and o traceptives are «contraindicated because they Cause fluid retention and promote thromboembolization. {. Most critical period ~ the period immediately following delivery because the 30%-50% increase in blood volume during pregnancy will be reabsorbed into the mother's circulation in a matter of 5-10 minutes and the weak heart must make rapid adjustment to this change. f, MULTIPLE PREGNANCY (TWIN PREGNANCY) , MULTIPLE ENS UN PREGNANCY) 1, Classification a. Monozygotic/Identical — twins begin as a single ovum and sperm, but in the process of fusion or in one of the first cell divisions, the zygote divides into two identica} but separate individuals, + * Characteristics — always of the same sex ~ ~ with 2 amnions, 1 chorion, 2 umbilical cords and 2 placentas fused as one. * Incidence ~ a chance occurence - More frequent among non-whites ~ More frequent among young primis and old multis b. Dizygotic/Fraternal — two separate ova are fertilized by 2 separate sperms. They are actually siblings growing at the same time in utero. * Characteristics ~ May or may not be of the same sex ~ With 2 amnions, 2 chorions, 2 placentas and 2 umbilical cords * Incidence - familial maternal pattern o} 2. Suspect multiple pregnancy if there is/are: * faster rate of increase in uterine size Sa OE eine Size * on quickening, several flurries of action in different abdominal positions * on auscultation, two sets of fetal heart tonés heard * marked weight gain (hot fi ue to toxemia or obesityi of/physical activity) ordi * Class Ill ~ moderate. to marked limitation of physica) activity; less than ordinary activity causes. fatigue, ete. * Class.1V - xeabieho carry on any activity Withoy, experiencing scomiort Prognosis + Classes | and Il - normal pregnancy and delivery * Classes Ill and IV ~ poor candidates. Signs and symptoms + Because of increased total cardiac_volume during pregnancy, heart murmurs are observed. * Cardiac output may become so decreased that vital organs are not perfused ‘adequately; oxygen and nutritional requirements, therefore, are not met. * Since the left side of the heart is not able to empty the pulmonary vessels adequately, the latter become engorged, causing pulmonary edema and hypertension. Moist cough in gravidocardiacs, therefore, is a danger sign. * Liver and other organs become congested because blood returning to the heart may not be handled adequately, causing the venous pressure to rise. Fluid then escapes through the walls of engorged capillaries and cause edema or_ascites. ; * Congestive heart failure is also a high probability because of the increased cardiac output during pregnancy. Dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion, and cyanosis of nailbeds are obvious. - Management - Consider the functional capacity of the heart. : poe eine i 5 *(Bed rest)- especially after the 30th week of gestation to ensure that pregnancy is carried to term or at least 36 weeks gestation *Diet > should gain enough, buCnot too Phuch as it would add to the workload of the heart * Medications x Digitalis b. Iron preparations, e.g., Fer-in-sol or Feosol - anemia should be prevented because the body compensates by increasing cardiac output, thus further increasing cardiac workload ¥% Classes IN and tv axa haces in lithotomy position during delivery tovoldincreasing venous return. The semi-sitting position is preferred to facilitate easy respirations. ee ;6, Infant of the Diabetic Mother (1pm) « Js typically longer and Weighs more because of: excessive S| upply of glucose from the mi other increased production of growth hormone maternal pituitary gland ‘mones from the — increased secretion of jnsulin from th sappy e feta ~ increased action of adrenocortical hormeneseesrens passage of glucose from mother to fetus at favor * Congenital anomalies are often seen i * More often born premature, so respirator distress syndrome is common * Lose a greater proportion of weight than normal newborns because of loss of extra fluid. * Are prone to the following complications: 7 (Hypogl fycemia) Blo ugar level is less than 30 mg%. It is the most common co} ion to watch for. Cause: while inside the uterus, the fetus tends to be hyperglycemic because of maternal hyperglycemia. The fetal pancreas thus responds to the high glucose level by producing matching high levels of insuJin. Following delivery, the glucose level begins to¢fall)because the baby has been severed from the mother. Since there has been previous production of high levels of insulin, hypoglycemia develops. Clinical signs of hypoglycemia: “shrill, high-pitched cry * listlessness/jitteriness/tremors * lethargy; poor suck * apnea; cyanosis* * hypotonia; hypothermia * convulsions Consequence: Hypoglycemia, i(not}reated, can lead to brain damage and even death. eae Management: Feed _with glucose water earlier than usual, or administer IV of glucose. ~(Hypocalce: nia - serum calcium level of less than 7 mg%. Signs: same as hypoglycemia Sequela: same as that of hypoglycemia Management: calcium gluconate to prevent hypocalcen tetany E. HEART DISEASE _ 1. Classification _ + Class 1 (fo limitation pf physical activity-~ made i olerance test de on the basis of the lucose toler Diagnosis a (GTT) Procedure * NPO after midnight kg of prepregnant body weight is . £50% gtucose/3 | ‘ 2 Oy ial tab t isholyadvisable because of known decreased gastric moti itydnd delayed absorption of sugar during pregnancy) Interpretation of results : * Ifless than JOO mg% : possible gestational d abetes) * If 100 - 120 mg% + If more than 120 mg% >Overt gestational diabetes) 4. Categories - to predict the outcome of pregnancy i ightly abnormal; minimal dietary * Class A - GTT is on slight minimal restriction; insuli knotyneeded; fetal survival is high * Classes C to E — have 25% erinatal mortalit Classes C to F 25% perinatal Ly * Class F - therapeutic abortion (in other countries may be justified, not in the Philippines) 5. Management ih * Diet - highly individualized. Adequate glucose intake (1800-2200 calories) to prevent intraurine growth retardation. * Insulin requirements are likewise highly individualized, requiring close observation throughout pregnancy. Since the effects of the hormones are more pronounced during the2nd and 3rd trimesters)there is an increased need for insulin. / ~ Insulin is regulated to keep urine +1 for sugar (minimal glycosuria is necessary to prevent acidosis) but negative. for acetone. ~ Long-acting insulin (Ultralente) will have to beChanged to regular insulin (Lente) during the last few w ot pregnancy. * Often delivered by CS : ~ Baby is typically larger or may be in distress because of placental insufficiency. ~ Severe metabolic imbalances in vaginal delivery can occur because of depletion of glycogen reserve in the liver and skeletal muscles by strenuous muscular exertion during labor. * Maximum difficulty in controlling diabetes is during the early postpartum peri i ¢ iod because of the drastic chan, in hormonal levels. cenanes*DIABETES MELLITUS ~ chronic hereditary disease chp acterized D. by hyperglycemia due to relative insufficiency o (lack of insulin) from the pancréas which, in tarry, normalities tn the ‘metabolism Of carbohydrates, ‘proteins and fats, 1, Diabetogenic effects of pregnancy - many women who have had no evidence of diabetes in the past develop abnormalities t . * Decreased renal threshold for Sugar because of increased Dosage: 10 gm Initlally, either by slow tv push over 5-10 minutes, or deep IM, S.gm/buttack, then an IV drip of 1 gm per hour (1 gm/100 mi. DIOW) IF: a. Deep tendon reflexes are present, b, Respiratory rate ts at Jeast 12 per minute _ c. Urine output is at least 100 mE M6 Ke rs Antidote for magnesium sulfate toxicity: Calcium gluconate, 10% IV, to maintain cardiac and vascular tone. E St sigh}of magnesium sulfate Loxicily; isappearance of the knee jer Kipaiellar reflex d. Method of delivery ~ preferably vaginal, but if hot possible, CS will have to be done. e. Prognosis: The danger of convulsions is present until 48 hours postpartum. in glucose tolerance. Effects include: estrogen, which is why it is common to find dextrose and lactose in the urine of pregnant women. : * Increased production. ofadenocorticoids, anterior pituitary hormones and thyroxin, which affect carbohydrate concentration in blood (hyperglycemia). * Rate of insulin secretion is increased but sensitlvity of the pregnant body to insulin is decreased, Le, insulin does not seem to be normally effective during pregnancy, Attendant risks * toxemia * infection . hemorrhage * polyhydramnios * spontaneous abortion (because of vascular complications which affect placental circulation) * acidosis (because of nausea ahd vomiting) ~ the chief threat to the fetus in utero * dystocia ~ due to excessively large babyf vasoconstriction nsion in toxemia is the result o! ang aoewed blood flow that diminishes the amount of nutrients and oxygen in cells. In any condition where there is a possibility of convulsions, bed rest should be in a darkened, non stimulating environment with minimal handling. b. » Formild preeclampsia ~ high protein, high carbohydrate, oderate salt restriction (no added table sajy, ncluding “bagoong”, “patis’, “tuyo”, canned gouds, tt bottled drinks, preserved foods and cold cuts) eee * For severe preeclampsia - high protein, high calorie and Salt-poor (3 gm of salt per day) c. fee Diuretics - ide/Diuril. “* Diuretics - e.g., chlorthiazi 1 reer urine output should be at least 20-30 mL (normally 60-60 mL per hour) ~ Pharmacologic effect: decreased reabsorption of sodium and chloride at the proximal tubules, fase thereby increasing renal excretion of sadium, chloride and water, including potassium. ~ Side effects: fatigue and muscle weakness due to fluid and electrolyte imbalance or — Nursing care: Closely monitor intake and output, Digitalis - if with heart failure. SSS pee - Pharmacologic action: Increase the force of contraction of the heart, thereby ‘decreasing heart rate. oo — — Important: shouldfot be given, therefore, if heart Bae rate is below 60/minute. - Implication: take the heart rate be iving the ae drug Potassium supplements — patients receiving diuretics oe ’ are prone to hypokalemia; if digitalis is given at the same time, hypokalemia increases the sensitivity of the heart to the effects of digitalis. Potassium supplements (€.g., banana) must be given to prevent ae cardiac arrhythmias. is * Barbiturates — sedation by means of CNS depression | | gé * Analgesics; antihypertensives; antibiotics; ae eo? anticonvulsants; sedatives : 4 y _pneeuty Magnesium sulfate}- the drug of choice ) Actions . -R R mF CNS depressant - lessens the possibility of- y fe as convulsions. P % b. casodilator - decreases the BP. c. cathartic causes a shift of fluid from the extracellular spaces into the intestines from wher the fluid can be excreted :¢ Details , 2. (expe) mpeonrahee of ‘© Underlying causes ~ insufficient production of blood and platelets ~ generalized vasoconstriction and associated microangiopathy (disease of Capillaries) ~ abnormal retention of sodium an body tissues * Medical complications ‘ ~ cerebrovascular hemorrhage — acute pulmonary edema — acute renal failure * Types : 1. Mild preeclampsia - signs and symptoms ~ Sudden, excessive weight gain of 1-5 Ib, - per week (earliest sign of preeclam sia) due to edema which is persistent and found in the upper half of the body (e.g., inability to wear the we ding ring). ~ Systolic BP of 140, or an increase of 30 mm Hg or more and a diastolic of 90, or ise of 15 mm Hg or more, taken twice §hours apart. ~ Proteinuria of 0.5 gm/liter or more. 2. Severe preeclampsia - signs and symptoms : ~ BP of 160/110 mm Hg —— ats ~ Proteinuria of 5 gm/liter or more in 24 ‘hours : id water by teem ~ Oliguria of 400 mL or less in 24 hours (normal urine output/day = 1500 mL). ~ Cerebral or visual disturbances ~ Pulmonary edema and cyanosis ~ Epigastric pain (considered an “aura” to the development of convulsions) b. |Eclampsia|~ the main difference between —— ETE preeclampsia and eclampsia is the presence of convulsions in eclampsia. Signs and symptoms are as in preeclampsia, plus: ; uf aun * Increased BUN ~ { * increased uric acid ~ * decreased CO, combining power ~ 4. Management a. Complete bed rest ~ sodium tends to be excreted at a more rapid rate if the patient is at rest. Energy conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered oxygen_ bimanual compression to explore retaineg placental fragments - ysterectomy b. aren fibrinogenemia (aclotting defect) - Mana : aoa transfusion) a Bemen = Retained placental fragments - Management: dilatation and curettage (D & Cc) hangs tee - fiematoma - due to injury to blood vessels in the per Derineum during delivery 1 Incidence: Commonly seen in precipi clive and those with perineal varicosities 2, Treatment * ice compress durin; first 24 hours * oral analgesics, as ordered * Site is incised and bleeding vessel is ligated, JUCED HYPERTENSION (PIH) ~ 2 vascular disease of cn cause which occurs anytime after the 24th week of gestation up to two weeks postpartum. 1. Triad of symptoms = hypertension , —* edema -* proteinuria (specifically albuminuria). 2. Predisposing factors * Age (primis under.20 and over 30 years) * Gravida (5 or more pregnancies) i * Low socioeconomic-status (SES) * Multiple pregnancies * with underlying medical conditions, e.g., heart disease hypertension or diabetes i 3. Diagn -over test }- assesses the probability of lone ‘oxemia when performed between the 28th and 32nd week of pregnancy. a. Procedure ~ Patient lies in the lateral recumbent position for ai minutes Until BP has stabilized. ~ Patient then rolls over to supine position. - BP is taken at 1 minute and 5 minutes after having jolled ove. SS b. Interpretation: If diastolic pressure increases 20 mm Hg or more, patient is prone to toxemia. iaeermaseaaes nr,Complications * hemorrhage * infection * prematurity (. Abruptio Placenta | Greiature venxy placenta CDicimature sepavaTTAor the Predisposing factors, * maternal hypertension or toxemia * increasing parity and maternal age + sudden release of amniotic fluid * short umbilical cord * direct trauma * hypotibrinogenemia Signs and symptoms * severe, sharp, knife-like, stabbing pain hi fundus —~— Labbing pain high in the « hard, boardlike uterus; rigid abdomen * signs of shock * concealed bleeding, if extensive, Causes uterus to lose its ability to contract. Tt Becomes ecchymotic and copper-colored, cllefCouvelare Wes) causing severe bleeding. Since the uterus no onger has the ability to contract, hysterectomy will have to be done. 2. Postpartum Hemorrhage Definition Blood loss of more than 500 cc Giormal blog T5sSyturing labor and delivery is 250-350 cc). The leading cause of maternal mortality associatéd with the childbearing. Classification : * Early postpartum hemorrhage: occurs during the, first 24 hours postpartum a. uterine atony — if the uterus i ell contracted, relaxed or boggy, this is the most frequent cause. Il. Predisposing factors : — overdistention of the uterus - e.g., multiple pregnancy, multiparity, excessively large baby, polyhydramnios — cesarean section ~ placental accidents (previa or abruptio) - prolonged and difficult labor 2. Management — massage -Gos)ursing action — ice compre: ~ oxytocin administration — empty the bladder—_—_ high frequency/above waves ofVe), e the fetus” rermittent der to wpictur ; in orde : audible range projected towards the . gounawaves back and converted into trical ee orded on a permanent graph pa er). jurasound re} aration for ? e patient, informing her Prep cedure to the P known ill effects, in the pro 0 ‘ ot is painle and there tient to take six nm adder but ask the pa : the blade rds in order tO dilate the ed bowel and, ~jasses of WALEE # ts places a gas ill bladder displa of the pelvis pladder. A fats petter visualization and its contents. ' ical uses Of ultrasoun Se agnose pr nancy aS early aS 5-6 weeks gestational . a establish that the fetus is increasing in size and, . ict EDC. therefore, can predict / + can determine gestational age by measuring the piparietal diameter of the fetal skull (if it is more than 3 ig more than 2 herefore, can rowth retardation, d anencephaly. 3.5 cm, it is ! diagnose intrauterine g microcephaly an d growth rate of the dentify poly- or oligo- nydrocephaly, * Can demonstrate size an amniotic sac; therefore, can i hydramnios. * can confirm placenta; there * Can diagnose m « Can visualize ascites, polycyst nd location of the presence, size a fore amniocentesis. fore, is valuable be ultiple pregnancy. ic kidneys, ovarian cysts, etc. « Can determine. baby's sex (during third trimester and if in cephalic presentation). signs and Symptoms — first and most constant Bpinless bright red vaginal bleeding due to tearing of placental attachment as a consequence of dilatation of the internal cervical os Management + Ensure the client gets full bed rest. ° sai vital signs of the mother and the fetal heart rate. * Prepare oxygen and blood. * * Internal examination (IE) fro ione If ever it is to be done, it has to be a doubte set-up (done in the Operating room wherein the patient has already signed ue vaavild form, preop medications have been given, minal prep has been done, etc., so that if ever placenta is accidentally detached, CS can be di immediately). : ae+ Highly positive urine test for pregnancy (that is why a positive pregnancy test cannot be considered a positive sign of pregnancy) + Nausea and vomiting is usually marked. * Rapid increase in fundic height. Rapid increase in weigh t. eee « Toxemia signs and symptoms appear before the 24th of gestation. etal heart tones. » 1 va inal bleeding seen as clear, fluid-filled, grape-sized vesicles. Management * D&C to evacuate the mole. * Prophylactic course of Methotrexate, the drug of choice for choriocarinoma. * Urine testing for one year to sinafoudit new villi are developing. Contraceptives (but northe pills) have to e used so as not to confuse the results. _ Incom tt Cervical Os — one that dilates prematurely. itis the chief cause of habitual abortion (3 or more consecutive abortions). i Causes * congenital developmental factors ¢ endocrine factors ¢ trauma to the cervix Signs and symptoms + presence of show and uterine contractions. * rupture of membranes * painless cervical dilatation Management: McDonald/Shirodkar-Barter procedure, acerclage procedure wherein purse string sutures are laced around the cervix on the 14th-18th week of gestation. These are removed during vaginal delivery (if McDonald's method, since sutures are temporary) or the patient delivers by cesarean section (if Shirodkar method, since sutures are permanent). Placenta Previa Cow implantatiomof the placenta so that it is in the way of the presenting part. Predisposing factors * Increasing parity * Advanced maternal age * Rapid succession of pregnancies Types -* Low lying —* Partial — Complete Diagnosis — made by means of symptoms and ultrasound (also known as Ultrasonic Echo Sounding or Sonar.)herapeutic abortion im performed by a doctor i Theat iat oF clink: wetting for a medic alee’ legal reancn Td alio khown as medical, Planned or tabortlan peat abortion (@ wher a{fetunaien IN Mero bug | Hal expelled Unuially dacavered at @ prenatal visit When findal he ht le measured ANd NO tncteaye ii deronastrated oF when previously heard fetal je fone are no longer prevent. IN Two Weeks! tine, nl ot abortion should occur, otherwise, labor wily Nave to be induced to prevent hypoflbrinogeneni, a: acpals ao Bctople Pregnancy any portation Gcate outside iy, levine cavily ; signs dad symptoms. Since the wall of the Vatlopian Tube ts not sulticlently efastic, tt tuptares: within the first 12 weeks of gestation as tt Can no Tonger Rive way for the growing fers, s severe, sharp, knife like stabbing pain in either the right oF felt lower quadrant (in bleeding wherein ther fino exit or egress of blood from the body, pain js the outstanding symptom, this pain differentiates ectople pregnancy from abortion) * right abdomen © (4) Cullen's sign bluish umbilicus * excruciating pay when cervix is moved on I, * signs of shock; falling BP, PR more than loo/minute, rapld RR, lightheadedness Munagement: A ruptured ectople pregnancy ts an omergency siluation, * Salpingostomy {Fallopian tube can still be replaced and preserved, but the pregnancy has to be terminated ‘ * Salpingectomy removal of Fallopian tube + blood transfusion Nursing cares Combat shock! * Elevate foot of the bed, * Maintain body heat through the use of hot water bottles and blankets. eines atidiform Mole developmental anomaly of the placenta tesulting in proliteration and degeneration of the chorionic villi, een oe Incidence: Thegnost common lesToD anteceding shorlocare noma. Laccurs most often in women: * trom low socloeconomlc backgrounds with low protein intake * over Jd years and under 18 years of age Signs and symptoms Because of rapid proliferation of the placental tissues and, therefore, high levels of eGpLEEDING/HEMORRHAGE B 1, Bleeding in Pregnancy N (Abortion! any interruption in pregnancy before the age liability. : Natural Causes of spontaneous abortion Blighted ovum/germ plasma defect is the@nos? common causé It is nature’s way of eliminating the’ birth of a congenitally defective baby. — Implantation or hormonal abnormality ~ Trauma, infection (e.g., rubella, influenza) or emotional problems . Types I ; Symptoms: bright red vaginal bleeding which is moderate in amount Management ~ Complete bed rest for@4-48 hours) If bleeding will stop, it usually stops within this time. ~ Coitus ested 2 weeks after bleeding has stopped in order to prevent further bleeding or infection, ~ Endocrine/hormonal therapy ~ ‘Advise patient to save all pads, clots and expelled tissues. 2.°]I nént/inevitable Symptom: Bright red vaginal bleeding which is moderate in amount and accompanied by uterine contractions and cervical dilatation. Loss of the products of conception is inevitable. ‘ Management: depends on whether the abortion is: ~ Complete (All products of conception are expelled; bleeding is minimal and self-limiting. No intervention is therefore needed.) - Incomplete abortion (Part of the conceptus— usually the fetus—is expelled, but membranes or placental fragments are retained. D & C is indicated as management.) * Induced abortion is never allowed in the Philippines.